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What’s your age?
18-25
26-35
36-45
46-55
56-65
65+
“Most of the time I feel”
Choose as many or few options as you like
Happy
Sad
Depressed
Anxious
Motivated
Lonely
Indifferent
Other
“I notice that I often”
Choose as many or few options as you like
Overthink and over plan
Struggle with making decisions
Feel anxious in social situations
Lack engagement in the activities I used to enjoy
Go out less than before because “I don’t feel in the mood”
Feel exhausted and fatigued at the end of the day
Other
Did you frequently experience any of the following problems in the last 2 weeks?
Choose as many or few options as you like
Panic or anxiety attacks
Feeling nervous, anxious, or on edge
Excessive worrying I wasn’t able to control
Trouble falling asleep due to worries
Getting irritated or annoyed easily
Finding it difficult to relax or enjoy activities
Feeling afraid something terrible might happen
Other
Which statements apply to you when you think about your job?
Choose as many or few options as you like
I feel exhausted with no energy to work
I notice that I am cynical and pessimistic towards my job
I don’t feel productive at work
I tend to procrastinate a lot
I have difficulties focusing and concentrating
I lack motivation for most tasks
I often feel stressed while at work
Other
How would you describe your sleep pattern?
Choose as many or few options as you like
I am satisfied with my sleep
I have difficulties falling asleep
I lie awake for long periods of time through the night
I often wake up throughout the night
wake up too early
I wake up not rested
Other
“When I feel emotionally or mentally overwhelmed, I tend to”
Choose as many or few options as you like
Self-harm
Comfort myself by eating
Sometimes become physically violent
Use alcohol or drugs to help me relax
Detach myself from others
Other
Select the physical symptoms that apply to you:
Choose as many or few options as you like
I tend to get digestive problems
I noticed some changes in my eating or sleeping patterns
I experience some heartrelated issues
I’m getting headaches more often
I have excessive perspiration, muscle pains, or a dry mouth
I feel fatigued
Other
Select the behavioral symptoms that apply to you:
Choose as many or few options as you like
I experience frequent mood swings
I feel uncomfortable in my own skin
I noticed some changes in my eating or sleeping patterns
I often feel that my head and my heart are telling me different things
I feel restless and agitated
Other
Which of these healthy activities do you perform regularly?
Choose as many or few options as you like
Exercise or yoga
Going for daily walks
Meditation
Taking time off work
Spending time with a close friend
Playing/walking with my pet
Other
Which statements do you relate to the most?
Choose as many or few options as you like
I lead a purposeful and meaningful life
My social relationships are supportive and rewarding
I am engaged and interested in my daily activities
I try to help others whenever I can
I am a good person
People respect me
I am optimistic about my future
I am competent and capable in the activities that are important to me
Other
Do you find it challenging to maintain relationships with colleagues or friends?
Very much so
It depends on my mood
Sometimes, but not often
Rarely
I never struggle with this
“I would like to”
Choose as many or few options as you like
Care less of what others think or say about me
Have a more stable and less anxious mood
Feel like I’m appreciated more
Feel better about myself
Be more productive and motivated
Stop feeling like I am worthless
Criticize myself less
Other
Which areas of life cause you the most worry or anxiety?
Choose as many or few options as you like
Being around groups of people
Not having enough guidance
Being alone
Ongoing stress
Health issues
Having tight deadlines
Being relied upon
Other
When you think about your motivation levels – what comes to mind?
I often feel motivated and excited to take on the day
I usually wake up feeling energized, but this drains throughout the day
I mostly feel drained and lack motivation
I never feel motivated
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